CASE 1
Q: SB is a 45-year-old woman who presents to the pharmacist-led clinic for an initial diabetes consult. She was given a diagnosis of type 2 diabetes (T2D) 3 years ago. SB has been maintained on metformin 1000 mg twice daily and glipizide 5 mg daily. Her hemoglobin A1C (HBA1C) has ranged from 6.8% to 7.4% since her diagnosis. At today’s visit, SB says she feels as if her medications are not working. Her blood sugars have been markedly elevated despite her ad- herence to a low-carbohydrate diet and daily exercise. SB denies acute illness. She also reports increased blurry vision, thirst, and unintentional weight loss over the past 2 months (body mass index, 21 kg/m2). SB’s HbA1c is 10.1% today. The clinical pharmacist suspects she may have latent autoimmune diabetes in adults (LADA).

What additional labs can the pharmacist order to confirm LADA, and what treatment options are available?

A: 
LADA shares characteristics of both type 1 diabetes and T2D. It commonly presents in adults >30 years and features autoantibodies such as glutamic acid decarboxylase and low levels of C peptide, a marker of residual β-cell function. SB’s age, symptoms, and previous but now poor response to oral agents further strengthen the case for LADA. Ordering both an antibody panel and C peptide level can help confirm a diagnosis. If SB has LADA, she should stop her oral medications, especially glipizide, as it will accelerate β-cell decline. She should be started on insulin therapy. Early initiation of insulin is shown to improve metabolic control while protecting β-cell function. Dipeptidyl-peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists, and thiazolidinediones could also be considered to preserve β-cell function. SB should be encouraged to continue her daily exercise plan and low-carbohydrate diet.

REFERENCE
Stenström G, Gottsäter A, Bakhtadze E, Berger B, Sundkvist G. Latent autoimmune diabetes in adults: definition, prevalence, beta-cell function, and treatment. Diabetes. 2005;54(suppl 2):S68-S72. doi: 10.2337/diabetes.54.suppl_2.s68.
 

CASE 2
Q: 
PL is a 37-year-old man presenting with a prescription for triamcinolone 0.1% cream for the treatment of bedbugs. The directions read, “Apply to the affected area twice a day for 10 days.” The quantity is missing from the prescription. As the pharmacist on duty, you call PL’s primary care provider. She informs you that PL should apply 6 fingertip units (FTUs) of triamcinolone to his right leg per application. She does not recall what size tubes are available and asks you to dispense
a quantity sufficient for the 10 days.

What is the minimum tube size that you should dispense?

A: 
The pharmacist should dispense a 60-g tube to PL. An FTU refers to the amount of cream or ointment that is squeezed out from a standard-size tube from an adult’s distal index finger crease to the tip. One FTU is about
0.5 g of product. PL has been instructed to apply a total of 12 FTUs per day (6 per application). He will therefore use 120 FTUs during his 10-day course of therapy (120 FTU × 0.5 g/FTU = 60 g of triamcinolone).

Counsel PL on how to appropriately squeeze out the product using the FTU method. Proper use will prevent application of too much product, which would predispose him to unnecessary adverse effects, as well as too little product, which would result in therapeutic failure.

 
Stefanie C. Nigro, PharmD, BCACP, CDE, is an assistant professor and a clinical pharmacist at Massachusetts College of Pharmacy and Health Sciences in Boston.

Rita El-Khoury is a PharmD candidate at Massachusetts College of Pharamcy and Health Sciences.